Understanding Indirect Inguinal Hernia

Understanding Groin Hernias: Inguinal and Femoral Hernias

Groin hernias are very common and one of the most frequent problems we see every day in clinic. Femoral hernias, direct, and indirect inguinal hernias are groin hernias as they are located at just above the junction of the leg and the abdomen. We see at least 10 men with a groin hernia for every female that we see with a groin hernia. Femoral hernias are not as common as indirect or direct inguinal hernias, but we see more women that have femoral hernias.

Indirect Inguinal Hernia

Overview

Indirect inguinal hernias are the most common type of groin hernia. Indirect inguinal hernias occur when abdominal content such as fat or bowel pushes down along the inguinal canal. What is the inguinal canal? It is the tunnel through which a man’s vas deferens and testicular vessels travel down into the scrotum. The same tunnel exists in females, but instead contains the round ligament, which is a suspensory ligament for the uterus. The existence of this tunnel, which takes structures from inside the pelvis downwards is a natural weak point in our anatomy. Men are much more likely to develop indirect inguinal hernias than women and the reason for this has always been assumed that the tunnel had to widen enough to allow the testicles to descend from the abdomen down to the scrotum. If one of the testicles does not descend, it is known as an undescended testicle.

Boise Indirect Inguinal Hernia Surgery & Repair

When You Have An Indirect Inguinal Hernia

Indirect Inguinal Hernia Symptoms

Sometimes the visible bulge in the groin is the first symptom. For parents with infants with indirect inguinal hernias the bulge is usually noticed when the baby is crying. Pain is the next significant symptom. Sometimes this is a dull ache and other cases can present as a sharp pain. The pain can radiate down the inner thigh or into the scrotum or labia. If bowel is involved with the hernia the pain can be even more difficult to localize as the patient may feel the discomfort in the abdomen or the pelvis.

Warning Signs

Indirect inguinal hernias are more likely to cause bowel obstruction than direct inguinal hernias. This is because that tunnel described above, the inguinal canal, can be narrow. The narrow area enlarges as the canal travels downward. The narrow area can strangulate the tissue which is further herniated down the canal. This happens because the herniated bowel or fat starts to swell. This usually causes intense pain. Other signs can be discoloration of the area of bulge. Usually red or a purple color occurs. If you are having any of these signs, call for immediate medical attention. When bowel is strangulated and it’s blood supply is disrupted, it can die in a few short hours. If the bowel is found to be dead in an area at time of operation, it requires a bowel resection. This horrible complication makes a routine operation much more of a problem for the patient and the surgeon. It can also lead to many more problems down the road for the patient.

Risk Factors

As mentioned above, being male is a risk factor for an indirect inguinal hernia. There is certainly a hereditary component to indirect inguinal hernias. Sometimes the patient will have a father, brother, or uncle that also had an inguinal hernia. Other times, patients have not heard of any other family members with a hernia at all. Smoking is a known risk factor for inguinal hernias.

When to Repair

Indirect inguinal hernias do not always require surgery when found. If the indirect inguinal hernia is small and not causing any significant discomfort, it may be observed by the patient and their physician. If you do think you have an indirect inguinal hernia, however, make sure you ask your physician’s opinion about it when you see them. Sometimes the diagnosis may be different from what the patient assumed.

If you are having groin pain, make sure you have the correct diagnosis. If it is an indirect inguinal hernia and you are having pain, you should probably have surgery.

Since the indirect inguinal hernia is an actual “defect” or a hole within the strong fascial layer with abdominal or pelvic content pushing through the defect, it will not heal without surgery. Because surgery was the only way to fix the problem, a hernia repair was previously recommended for all indirect inguinal hernias because as the hernias enlarge, they are more difficult to repair, the risk of a recurrence of the hernia after repair goes up, and there is always that risk of bowel strangulation discussed above which can be catastrophic.

In certain patients, a hernia truss may get them by without surgery. A truss is usually made out of an elastic strap which goes around the waist and a part of the truss holds pressure against the bulging groin hernia. Hernia trusses are usually used in elderly patients or others who may not be good candidates for surgery due to their other medical problems. Those who want to be active and return to their normal function usually go to surgery, but a truss can sometimes get these patients through a time while they wait for a more convenient time for surgery. Hernia trusses can be purchased on the internet.

Repair Options

In infants and children prior to puberty a non-mesh repair, or suture only repair is the accepted standard of care. Although, on some large children a mesh repair may be necessary.

Mesh repair is the standard of care for indirect inguinal hernias in adults in the United States. There are also several suture only repair techniques, but these are not widely used any longer because of the ease of use and recovery of the patient using hernia mesh and the very reliable repair it creates. Indirect inguinal hernias were historically repaired without mesh, but the recurrence rates were unacceptably high and the use of hernia mesh in the 1990’s became the standard. The mesh can be made of different materials. The choice of mesh material should be discussed with your surgeon if you have questions.

Laparoscopic repair or open repair of indirect inguinal hernias are both performed in our practice. The of type repair chosen also depends on patient factors and should be discussed. There are pros and cons to each of these approaches and therefore one is not necessarily “better”. Most patients do well with a very small “open” incision.